Category: emr-ehr-usability

The Health IT Standards Committee Health IT Implementation/Usability Hearing (agenda) was held today (July 23rd, 2013) in Washington DC. There’s lot of material posted online pertaining to the hearing, PowerPoints, position papers, questions and answers, etc. As I always do, when it comes to EHR and Health IT usability, I search through everything to find all references to “workflow,” to understand the contexts in which it is used and its intended meanings. My reactions are at the end of this post.

The following are slides or quotes from the three most relevant links.

“Other than patient safety, from the vendor perspective, the largest issues in usability revolve around two key concerns: Configuration/Personalization and workflow….

to design and evaluate the usability of a product or service, one needs to understand the users, the workflow, and the context of use. Because these elements are so dynamic in the healthcare domain, it poses significant challenges to design for optimal usability….

the complexity of addressing usability issues in a highly customized environment with numerous user profiles, workflows and configuration options is significant….

Additionally, Allscripts offers optimization services where clinical consultants will work with clients to optimize their process, workflows, and product configuration to ensure successful outcomes. As an example, we suggest “certified clinical workflows” in our Enterprise EHR product that clearly define the optimal clinical workflows for common tasks in the product….

layers of prescriptive regulatory compliance are in fact hampering our ability to adapt to the changing landscape….

the software development industry wants the goals and the measures but not to be told how to do it. We can determine the How if you tell us the What….”

“The requirements in the Meaningful Use (MU) program stipulate a myriad of measures and objectives that physicians must fully meet in order to receive incentives and avoid reimbursement penalties. EHRs are predominantly engineered to capture MU data and often require additional steps outside the physicians’ workflow – shifting focus away from patient care….

regardless of their specialty, patient population, geography, or practice size, with limited exceptions, physicians are required to collect the same exact data on each and every patient even if a measure is not relevant to the patient’s visit, service, or is rarely used for clinical practice.

Stage 3 MU requirements should align measures in a way that does not require physicians to perform additional actions either due to limiting factors or that are outside their patient mix.”

First of all, let me congratulate all involved, who brought up or even focused on workflow at this hearing. It is, I believe, the single most important obstacle, and opportunity, to greatly improving healthcare quality while reducing its costs.

My only quibble (and it is a big, maybe even enormous, quibble) is virtually all current discussion of workflow, including today’s, occurs outside the context of knowledge of, and experience with, modern workflow technology. I’ve over 200 blog posts on this blog, EHR Workflow Management Systems, and well over 20,000 tweets on my Twitter account at @wareFLO on exactly these topics. So, I (to use the cliche phrase) know of what I speak.

Let’s start with the first slide. Well Developed User-Centered Design involves detailed workflow analysis and safety data. See my blog post User-Centered EHR Design Considered Harmful (Try Process-Centered Instead) for my critique. Mind you, at the end of that blog post I do admit that some User-Centered Design practices are beginning to focus on workflows, but the problem is, they don’t occur in the occur in the context of highly-instrumented (relevant to patient safety data) highly-malleable workflows (most current EHRs are workflow oblivious). Just think if these sophisticated efforts to understand and improve EHR and health IT workflow were applied to EHRs based on workflow management systems, business process management suites, and sibling dynamic/adaptive case management software. I believe this will, in fact, happen. Eventually!

The next material comes from a well-known EHR vendor. Again, it’s accurate as far as it goes. Configuration and personalization of workflow is the key. Healthcare is indeed a challenge, due to a combination of structured and unstructured workflows (note, I’m talking about workflow, not data, though there is a connection). It is equally true that well-intended meaningful use regulations hamper workflow innovation, both at the level of improving current workflows, and adopting the healthcare workflow tech I advocate. However, I must disagree with the last sentence in the quote: “the software development industry wants the goals and the measures but not to be told how to do it. We can determine the How if you tell us the What….”

Finally, the AMA states (my paraphrase) that Meaningful Use has reduced physician productivity. So true. And in the face of already runaway healthcare costs. Reduced productivity means that physicians can see fewer patients at the same level of care quality, or can only see more patients while suffering reductions in level of care quality.

As I wrote in my blog post, Fixing Our Health IT Mess: Are Business Models or Technology Models to Blame? there is no way out of software development’s “Iron Triangle” of Scope versus Resources versus Schedule, except to move to clinical systems implemented on truly open workflow platforms. In other words, regardless of the eventually scope of Meaningful Use negotiated among constituencies and stockholders, achieving its long-term goals requires the same kind of process-aware, workflow-aware information systems already much in favor and use outside of healthcare.

H-EHR-T stands for Healthy Electronic Health Records Technology. I’m getting pretty good at catchy acronyms. Checkout S.Y.S.T.E.M., which stands for Saves You Substantial Time, Effort, and Money. Anyway, I had a Twitter convo with @SmyrnaGirl leading to her EHR Valentines Day post. So I might as well write one too!

There’s not much to this post. It’s just a place to collect a bunch of tweets for future reference. Maybe I’ll RT one, once-in-a-while. If I use HootSuite, and schedule the retweets, I’m good for a decade of Valentines Days!

I recently stumbled on this presentation about Activity-Centred Design (British spelling). I thought several of its slides (adapted) would make a nice table about benefits versus drawbacks of user-centered versus activity-centered approaches to design.

Benefits

Drawbacks

User-Centered

Improved usability

Fewer errors during usage

Faster learning times

Humanises software processes

Minimises guesswork

Understands user’s cognitive style

Reduces user mistakes and improves recovery

Focuses on the user

Improvements for one group of users can be detrimental to another

Users are moving targets

Users don’t always know what they want

Research is expensive, unreliable, time consuming

Tries to fix human mistakes rather than focussing on users accomplishing a task

Activity-Centered

Users can adapt better than the technologies

Active observation vs passive observation

Internal data: Statistics, heat-maps, eye-tracking

Learn about user behaviour, rather than the user

Activity has purpose. User has behaviour. Purpose is more predictable than behaviour

UI evolves over time to facilitate user activity

Uses analytic and cognitve data from users

Solves problems instead of user mistakes

[I’m sure there are disadvantages to activity-centered design, but none were listed in this presentation]

The two big Health IT conferences I’ve attended, repeatedly, over the years, are HIMSS and AMIA (even back when it was SCAMC). I always root around their on-line programs, looking for presentations about EHR and HIT usability, workflow and natural language processing. This year AMIA is in Chicago, November 3-7. The City of Chicago has even declared Chicago Informatics Week (love that logo, especially the skyline reflected in the lake).